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Pathway to Medicine

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This seems like an intuitively obvious question when planning your medical career- how do you go from high school student to fully licensed physician? Unfortunately the answer is region-specific. For this post, I’ll focus on North America and then prepare a subsequent post for the UK and Australian readers out there.

Ideally, you’d want a linear progression from one level of schooling to another (Figure 1) – this is rarely the case.

 

pathway1

It really ends up being more of a mixture, with one person’s pathway to medicine not necessarily mirroring another’s (Figure 2).

pathway2

Secondary (High) School: Grade 9 -12.

Your high school transcript will almost never be seen by a medical school – this is your opportunity to explore your interests and learn about all the different careers you can grow up to pursue. Academically, you will want a mix of science and non-science courses – make sure your science courses include physics and chemistry because the university equivalents of those courses may be required when in applying to medical school. Your goal here is simple – get into a good university that aligns with your needs as a student and will let you pursue the field of study of interest to you. This is also a good time to pursue volunteer opportunities – physicians often have integral roles in their communities; you don’t have to be a licensed medical practitioner to do the same. Finally, establish good study skills – these will be necessary as you progress academically; like all good things, they take practice to develop.

Undergraduate

I’ve already posted a fairly detailed synopsis of selecting an undergraduate major here. Usually around year 2-4 most students will take the MCAT. Depending on where in North America you’re located, it is possible to gain entry into medical school before completing your degree ie. after your 3rd year. However, by far the standard approach is to complete a 4 years Honours Bachelor of Something (Science, Arts, etc). Occasionally, students may also pursue an additional 5th year of study to further boost their GPA or complete prerequisites.

Medical School

Perhaps the topic of a future post: “The Structure of Medical School”. The abridged version of that post is that this is where you’ll learn the foundational knowledge of being a physician. You’ll learn how the body works when it’s healthy, unhealthy and then how to apply that knowledge to patients. Conventionally, medical school is taught in 4 years but there are a few schools that have accelerated programs (without summer vacation) where it’s possible to finish in 3 years- McMaster University, I’m looking at you.   Typically the 4 years are divided into 2 years of basic sciences and 2 years of clinical sciences; which all culminate with….another application! This one is to a residency in a specialty of your choice.

In the United States, medical students will take the United States Medical Licensure Examination (USMLE) Step 1 at the end of year 2 (the completion of basic sciences). This is followed by Step 2 Clinical Skills (CS) and Clinical Knowledge (CK) towards the end of 3rd year into 4th year, prior to starting residency. For our friends who have gone abroad and will be International Medical Graduates (IMGs) – the tests are the exact same.

In Canada, medical students will write the Medical College of Canada Qualifying Exam 1 (MCCQ1) during their final year of medical school. For IMGs, they must complete the Medical College of Canada Equivalency Exam (MCCEE) and the National Assessment Collaboration (NAC) Objective Structured Clinical Exam (OSCE) prior to completing the MCCQ1 and applying for residency in Canada. The MCCEE has similar content to USMLE Step 2 CK and the NAC-OSCE is similar in nature to USMLE Step 2 CS.

Residency

After the broad learning of medical school, residency will focus your knowledge into a specific specialty of interest. This can vary from General Surgery to Internal Medicine, Pediatrics, Obstetrics and Gynecology, Radiology, etc. The length of residency varies depending on the specialty and location. For example, Family Medicine is a 2 year residency in Canada and 3 year residency in the US. While Emergency Medicine is a 3-4 year residency in the US, it’s a 5 year program in Canada. I’ll make a chart in a subsequent post to compare the country differences.

The ‘medical school style’ general medical examinations are not over yet! In the US, after graduating from medical school and either in residency or prior to starting, it’ll be necessary to complete USMLE Step 3. In Canada, the MCCQ2 awaits you.

At the end of residency, two options exist – (a) subspecialty training (ex. Cardiologist, surgical oncologist, etc) or (b) Enter into practice – be it your own or joining a pre-existing one. After residency, you’re eligible to complete the board licensing exam for your given specialty – this may be a written and/or oral examination.

Fellowship

By now, if you’ve been reading along, this is probably self-explanatory – you will have focused training in the subsection of your given specialty of interest. Just as with residency, the duration and content of fellowships will vary depending on location and area of study. Most Internal Medicine subspecialties (Critical Care, Endocrinology, etc) are 3 years in duration; surgical subspecialties are 1-3 years (Colorectal and some trauma fellowships are 1 year in the US; plastic surgery is 3 year; vascular surgery is 2 years). It is possible to do more than one fellowship (unlike residencies, where most people usually only complete one).

Graduate School

I’ve put graduate school off to the side as an amorphous entity that can factor into your medical career as much or as little as you’d like it to. Some students only want to be clinicians and will be accepted into medical school directly from undergraduate and go on to complete their training, open a practice and never look back. Other students may apply to graduate school at any given point to improve themselves (and their application) for their career. This can include the undergraduate student who wants to improve their academic standing, or the resident that is demonstrating their interest in a particular subspecialty.

Unlike undergraduate studies where it can be a “free-for-all” decision about what to study; graduate education should ideally be more focused on a medically relevant discipline. This can take the shape of lab/bench research or clinical outcomes or public health to give a few examples. Remember, at some point you’ll have to justify why you went to graduate school and how it pertains to your future.

Practice

This is a vastly complicated area also known as “life”. For completeness sake; scope of practice has plenty of options, including private practice, hospitalist or group practice. Depending on what specialty and/or subspecialty there may be recertifying examinations every 4-7 years. If you are a board certified physician in your given specialty, there may also be a certain number of Continuing Medical Education (CME) credits that you will have to obtain in a given time period to ensure that you are providing current care for your patients.

In short, it’s a long road with many twists and turns. A stomach full of courage and a little bit of stubbornness can get you a long way. It’s best to remember that the journey to being a physician is a lifelong pursuit, not merely a series of sprint races.

Links!

Medical College of Canada Examinations: http://mcc.ca/examinations/

United States Medical Licensing Examination: http://www.usmle.org/

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